Provider Demographics
NPI:1013398783
Name:MISKOVICH, CAMILLA L (DMD)
Entity Type:Individual
Prefix:DR
First Name:CAMILLA
Middle Name:L
Last Name:MISKOVICH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:CAMILLA
Other - Middle Name:L
Other - Last Name:MISKOVICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:1730 MATTHEWS TOWNSHIP PKWY STE D
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-4928
Mailing Address - Country:US
Mailing Address - Phone:704-703-7232
Mailing Address - Fax:
Practice Address - Street 1:1730 MATTHEWS TOWNSHIP PKWY STE D
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4928
Practice Address - Country:US
Practice Address - Phone:704-703-7232
Practice Address - Fax:704-703-2327
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 21214122300000X
KY9604122300000X
NC106031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentist